Former CMS Administrator Weighs in on Advantage Plans


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Becker's sat down with Don Berwick, MD, who served as CMS administrator during the Obama administration and is a current health policy lecturer at Harvard Medical School in Boston, to discuss where the Medicare Advantage program stands and potential reforms in the coming years.

Dr. Don Berwick: I think the original ancestral idea of Medicare Advantage to allow Medicare beneficiaries to have the advantage of properly managed care that is coordinated, proactive and population-based was a healthy impulse 30 years ago. Based on the track record of the best managed health plans at that time, it could have reduced costs by a substantial amount, or about 10% to 15% lower costs compared to Medicare then. Who would not welcome better care and lower costs at the same time? But that's not what happened.

Over time, financially driven interests, especially insurance companies, recognized that given the rules around Medicare Advantage, they could continually increase their revenue per beneficiary and make the program very attractive by offering zero premiums and extra benefits. It was quite a deal. Over the past decade, Medicare Advantage became the most profitable component of many major insurance companies around the country. It did not, in my opinion, fulfill its original promise of saving money. I'm thoroughly convinced now that apples to apples, Medicare Advantage plans cost the taxpayer, the Medicare trust fund and even beneficiaries, much more than traditional Medicare does.

I was in the insurance business, running my own office from @1984 until Oct 2023 (retirement). From day one I was a proponent of Advantage Plans and then cancer hit. In Jan 2021 out of the blue, within two days, my wife was diagnosed with AML Leukemia. The closest hospital that could handle the AML said, if their treatment doesn't work, 2 weeks to live. It kind of worked but two months later of living in the hospital, they were at the end, they took me aside and said, all we can offer is palliative care. What? They already admitted they messed up, previously telling me, "something went wrong, we don't know what went wrong but we have to figure it out, so it doesn't happen again." Me being the advocate stepped in, I had been living in her hospital room (Covid time) and had a lot of time to work on research. This hospital is #32 in the list and Johns Hopkins Baltimore is #4. Gotta get to JHH. The hospitals were equal distance from my home, both 55 minutes. Except JHH was out of State (I live close to State line). Medicare Care Advantage carrier said --- oops you can go to JHH but it will be OON. Lucky for me, we had a pocket full of money, something the general population won't have but it was something we had to do.

Bone marrow transplant completed at JHH and she has been cancer free and one more bone marrow biopsy in March 2024 and if clean oncologist fires her. A big problem was the Advantage Plan Networks. Being close to the State line made an out of State hospital, one that has better outcomes the natural choice. Next choice was 300 miles away but that hospital was still double digit outcomes.

Many, many, many denials from the insurance company. On the phone conversations I told them about my experience with insurance and we will be talking the same lingo. Then there were the meds, the plan D type stuff. You get cancer and you are almost immediately in tier 4 meds and some that need prior approval. Xospata (Gilteritnib) was just one med out of a big basket, that took a fight. It was a $30,000 a month lifesaving immuno drug for AML relapsed patients. It was a med that worked but the Just for that med we ended up paying five digits a year out of our pocket. Each year we hit catastrophic tier by February.

After a bone marrow transplant you eventually need all your childhood immunizations again. Yeah that was a problem and cost us several thousand out of pocket, they would not even pay toward OON.

I now have a very bad personal taste, experience with an MA plan and their Network plan. Our Network was PPO and God help any patient that is in an HMO. Between what they 100% balked on coverage, the OON costs, etc. the cost would be something that will bankrupt many, many people in the general population. It drained a lot of money from our account, last Oct I sold my agency and recouped some money.

I have also firsthand experience the difference in life saving medicine of one hospital and the other #32 hospital. If I had not been the advocate to get her out of that #32 hospital they would have placed her in a SNF to die.

So yep - my first-hand experience showed me that MA Networks are a big problem. And I say find a med supp without a network. I've been around forums long enough that I am already putting my flame suit on and ready for the "the plan you chose was your choice." Yep - I was a believer in MA plans and bought my own sale pitch. My pitch now is traditional med supp and find a good cancer policy. Is there such a thing as a good cancer policy? Been decades since I looked into selling them.

My wife can walk, not far, she's in daily constant peripheral neuropathy pain but other than that she is doing well. It was a humbling experience.
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@URDRWHO . . . wow (not in a good way). Thanks for sharing your story, I know this was difficult to live through and painful to relive as you shared your first hand experience.

You probably know I am a strong proponent of OM + Medigap for a number of reasons . . . cancer being one of them.

Most of my wife's family has been wiped out by cancer over the last 40 years or so. Cancer claimed her father in 1980, mother in 1997 and her brother in 2023.

Everyone of them, except her brother, had original Medicare . . . a few had a supplement plan and those that did not had deep pockets.

When a doctor mentions the "C" word the first thing after the panic is, where can I get the best possible care.

With exception of her brother, all of her relatives got the best care available at the time.

Your story resonated with me on so many levels.

It sounds like your wife has made it over the big humps and hopefully can look forward to a long and healthy life.

Perhaps your personal experience will open a few eyes here.

take care,
I try not to think to hard about the past three years because if I do, darkness creeps in and I start to remember all the bad and lonely nights. Aside from living in the #32 hospital for almost two months, JHH required a 60 day stay. JHH is great. The first hospital can be known for famous chocolate and that's all I'll say about them.
Everything that came up, the problems, etc. Hopkins was already waiting in the wings. It wasn't their first rodeo. Around 18 months post transplant when she got fungal pneumonia, they were not surprised and knew what to do. Cytomegalovirus (CMV) on (X) day after transplant, yep they aware and already checking for it. There are hospitals that don't even check for CMV. Before the meds to handle it, CMV was the #1 mortality for bone marrow recipients. Average person CMV is no big deal, most have already had it but to a transplant patient it is a very BIG deal.

Of the 12 houses around me, I can count 9 cancer diagnoses. Three didn't make it. My mother had non-hodgkins lymphoma at age 88, my brother in law has melanoma (age 79). The C is all around us and it is so darn important to have the coverage in place to handle the big C. It is a matter of living or not living.

I became and expert on reading a CBC and what the values should be. Man I wish that I never had to gain such knowledge.

I'm thinking of hitting the sales lane again, to come out of retirement and talk to people about their Medi planning. The entire MA arena is almost like a con job and pulls people in with a suckers bet. Did that make sense? Boy I'm walking a tightrope with the MA salespeople on here. Yikes.
Oh, the mapd cult agents will be along soon. Can't wait for their responses.....or silence. Since it's not an article, there is a chance they will believe you.
I've been in Senior market since 1982. Probably wrote the very first MA application in state of Oklahoma. Before MA part of our conversation with clients was whether you are Warren Buffet or Joe Blue Collar, with Medicare everyone has identical access to care.
That is no longer true. We now have a 2 tier system when it comes to Medicare.
Funny thing though it doesn't really matter till your life is at stake.
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@URDRWHO in the south, we refer to this as your "come to Jesus" moment.

Thanks for continuing to share this life lesson.

You are 100% correct. Living in those facilities I witnessed people who fought for their life but didn't make it. Some were gone in a few weeks. There you are fighting for your life and the other side of your mind is the fight to receive medical treatment. Without an advocate, you are in really, really bad shape.

I stopped selling MA plans a long time ago and focused on commercial insurance. I put my P&C license to good use.

As for networks. I think if they are to continue, they should not be local but more regional. That way you would more than likely, have a center of excellence to treat your particular condition. East coast would snag the Hopkins, the Sloan, etc. Midwest would get you to your Cleveland Clinic. West coast would get your MB Anderson. Something like it.

Imagine living in the middle of nowhere and your local hospital can't even treat leukemia let alone do a bone marrow transplant. But that local 100 > 200 bed hospital is your in-network hospital. You don't make much money and you would have a center of excellence hospital across the border but hey - you can't get to it because you can't pay the OON. cost. Can you tell I'm kind of on a mission?
As for networks. I think if they are to continue, they should not be local but more regional. That way you would more than likely, have a center of excellence to treat your particular condition. East coast would snag the Hopkins, the Sloan, etc. Midwest would get you to your Cleveland Clinic. West coast would get your MB Anderson. Something like it.

Not necessarily . . .

The hospital clinics you mention are either out of network to all but a few local MA plans or don't accept any of them. Mayo has been for MA then against them and then for them. I can't keep up with them any more.

For the rest of that gang, if you search their website for MA insurance they accept you see things like this . . .

If you are enrolled in a managed care plan (HMO, PPO or POS), your treatment at MD Anderson may be covered by insurance. Before scheduling an initial appointment, please call your health plan/insurance company and ask if you have access to health care services at MD Anderson. We encourage you to refer to Questions to Ask Your Insurance Company when speaking to your insurance provider.

If MD Anderson is not a participating provider, you may still be able to receive treatment here. Contact your insurance company and ask about obtaining authorization. It is important to note that some benefit plans utilize what are referred to as "narrow" or "limited" networks; that is, they further narrow or limit the choices of doctors and hospitals that their customers can use. Often, these networks exclude MD Anderson. Additionally, some plans, such as HMO’s, have primary care physician referral and/or other authorization guidelines.

Your MD Anderson patient access specialist will help you obtain the full benefit from your insurance plan by:

Answering your questions about insurance verification and/or prepayment requirement
Responding to insurer requests for additional medical information.
DISCLAIMER: MD Anderson's participation with any product or insurance plan is subject to change without notice. Additionally, insurance companies offer a variety of plans and may change the names and benefits at any point. A patient’s level of coverage depends on the specific benefits outlined in their plan.

To ensure that MD Anderson and its physicians are in-network, it is the patient's responsibility to verify that MD Anderson is a participating provider and their benefit plan allows them access as of the day of a visit and/or admission. Please contact your insurance plan to obtain this information.

Revised 2/23/2023

We MAY admit you but you will need to jump through a bunch of hoops plus sign an agreement that you are responsible for paying claims that are denied or where there is a spread between what your carrier pays and what we bill.

My guess is very few people are willing to take that kind of beating and are willing to sign on for an OOP without caps . . . which is essentially what this kind of arrangement turns out to be.

There are any number of reasons why specialty clinics refuse to participate in MA plans, or only contract with a very small number of plans.

Here is another phrase that comes to mind, but it did not originate in the south. Put some lipstick on that pig . . .

There is not enough lipstick to make these hospitals want to accept MA plans into the fold.

And yes, I can see you are singing a different tune but you are tilting at windmills.